SURGICAL SAFETY CHECKLISTS Power Play: Managing the Forces that - PowerPoint PPT Presentation

1 SURGICAL SAFETY CHECKLISTS Power Play: Managing the Forces that Impact Implementation The Experience of a small isolated community hospital Presentation by: Mark Balcaen. March 8 -9 , 2010

2 Background • Kenora (230 km from Winnipeg) • 84 beds (Med/Surg/Mat/Peds/Psych/Chr) • 2 General Surgeons • 3 Visiting Specialist Surgeons • 8 Dentists and 3 GP’s Doing Minor Surgery • 5 GP Anesthetists • 8 Surgical Services Nursing Staff (3 OR’s) • 2400 Surgeries / Procedures per Year (80%+ NFA) • Ontario Wait Times Strategy Site

3 Previous Practice • Nursing OR Checklists. • Surgeons Preference Cards. • Procedure Consent Form. • Patient May Have Been Anesthetized Prior to Entire Surgical Team in the OR. • Communication problems between ST members.

4 Impetus to Adopt • Lack of Mind-Reading OR Nursing Staff • Incident Reports related to Intraoperative Issues  OR Lab Specimen Errors  OR Equipment and Supplies Issues  Anesthesia Related Incidents • Possible Means to Address Long-Standing OR Communication Issues • Desire to be “ahead” rather than to “Catch - up” • No Significant Additional Resources Needed

5 Roll Out Approach • Slowly • Gain Support as You Go • Identify Key Champions • Excellent CPSI Tool Kit • Persistence

6 Implementation • Feb 19/09 SSL Presentation to Hospital SSC and Senior Management Apr 10/09 Trial Checklist in OR Evaluate Checklist Trial Revise Checklist as Necessary Retest Checklist Start Monitoring and Recording Results • Apr 23/09 Report Successes, Good Catches, Near Misses. Make Checklist Modifications Continue Monitoring Results • Apr 30 / 09 Brief SS Group on Findings Celebrate Successes

7 Your Your Organizational Organizational General Surgery Lake of the Woods Your Your Logo Logo Organizational Organizational District Hospital SURGICAL SAFETY Logo Logo CHECKLIST www.safesurgerysaveslives.ca  BRIEFING – Before induction of anesthesia  PAUSE / TIME OUT – After draping / All team members in the theatre and names written immediately before incision on white board beside corresponding roles (observers Surgeon, Anesthesiologist, and Nurse verbally included) confirm  Patient information confirmed  Patient Identity (2 identifiers)  Procedure Consent: Site and procedure (by nurse)  Site Site, side and level marked  Side  Level Clinical documentation: History, physical, labs, of significance Is prep solution dry? ANESTHESIOLOGIST: (WITH ALL TEAM) Is all equipment connected and ready to proceed?  Anesthesia equipment safety check completed “Does anyone have any other questions or Check sheet placed on patient chart concerns before proceeding?”  ASA score  Special precautions? _________________  DEBRIEFING – As soon after skin closure as  Allergies? __________________________ possible / before patient leaves OR  Medications  Beta blockers? All team members review with entire team  Glycemic control meds? Surgeon states procedure performed  PreOp Anticoagulant therapy (e.g., Warfarin)?  Preop Antibiotic administered Important intra-operative events Anesthesiologist reviews intraop events  Difficult Airway / Aspiration Risk Recovery plans where there are KEY Confirm equipment available if required: concerns for this patient’s recovery and  Specific patient concerns, critical resuscitation management plan Changes to post-operative destination?  Monitoring – vs, O2 sat, Temp Probe, Nurse reviews:  Foley, Bair hugger (if applicable) Surgical count correct  If blood loss issues Specimen labeling accuracy  (G & M done & in chart)  Any equipment malfunctions? Action taken? SURGEON : (WITH ALL TEAM)  _______________________________ Specific patient concerns, critical steps, and  _______________________________ Special instruments or implants  _______________________________ Final optimal positioning of patient NURSES: (WITH ALL TEAM) Sterility indicator Could anything have been done to make Specific patient concerns? this case safer or more efficient? Equipment / implant readiness

8 Pre-Anaesthesia Apparatus Checkout  Secure connections between terminal units (outlets) and anaesthetic machine A. A. Pipelines 1  Turn on machine master switch and all necessary electrical equipment B. B  line oxygen (40 – 60 psi or 275-415 KPa) C.  line nitrous oxide (40 – 60 psi or 275-415 KPa) D.  Check here  adequate reserve cylinder oxygen pressure if this is a  adequate reserve nitrous oxide content repeat case  check for leaks and turn off cylinders today with  flow meter function of oxygen and nitrous oxide over the working range. this machine: 2.  vaporizers filled /  filling port closed /  on-off functions work E. 3.  Functioning oxygen bypass (flush) F. CHECKED  items ____ 4.  Functioning oxygen fail-safe device 5.  Attempt to create a hypoxic 02/N20 mixture and verify correct changes in flow and/or alarm to _____ 6.  functioning common fresh gas outlet 7.  ventilator function verified 8.  backup ventilation equipment available and function  cylinder,  Ambubag 1.  circuit correctly assembled &  presser checked C. Breathing 2.  connected to common gas outlet Circuit 3.  Oxygen flow meter turned on 4.  Check for exit of fresh gas at face mask 5.  Functioning high pressure relief valve 6.  Unidirectional valves and soda lime 7.  Functioning adjustable pressure relief valve  Suction adequate D. Vacuum  Correctly connected to patient circuit and functioning E. Scavenging 1. 1.  Airway Management F. F. Routine  Functioning laryngoscope (back up available) equipment  Appropriate tracheal tubes: patency of lumen and integrity of cuff  Appropriate oropharyngeal airways  Stylet  Magill forceps 2. 2.  IV supplies 3. 3.  BP cuff of appropriate size 4.  Stethoscope 4. 5.  ECG monitor 6.  Pulse oximeter 7.  Capnograph 8.  Temperature monitor 5. 9.  Functioning low and high pressure alarms A.  Adequate supply of frequently used drugs and intravenous solutions G. G. Drugs  Resuscitation apparatus is present and working H. H. special  Defibrillators / crash cart  Emergency drugs  Difficult intubation kit equipment  Glidescope  bronchosope Anaesthetic Machine Room Number:  O.R. # 1  O.R. # 2  O.R. # 3 DATE of inspection_________ TIME of inspection _____________ Anaesthetist Signature: _______________________________ Place patient identifier sticker here Canadian Anesthesiologists’ Society , 2008.

9 Your Your Organizational Organizational Cataract /IOL Surgery Your Your Lake of the Woods Lake of the Woods Logo Logo Organizational Organizational SURGICAL SAFETY District Hospital District Hospital Logo Logo CHECKLIST www.safesurgerysaveslives.ca  BRIEFING – Before induction of anesthesia Hand-off from day surgery nurse All team members’ names written on white board beside corresponding roles  PAUSE / TIME OUT – Before incision  Anesthesia equipment safety check completed Surgeon, Anesthesiologist, and Nurse verbally Check sheet placed on patient chart confirm Suction available  Patient  Site, side  Patient information confirmed  Procedure Identity (2 identifiers) Consent: Site and procedure (by nurse) “Does anyone have any other questions or BIOMETRY (confirm patient ID on sheet) concerns before proceeding?” (by ophthalmologist) Clinical documentation: (by anesthetist)  History, physical, labs, of significance  Special precautions?__________________  Allergies? _________________________  Medications  EYEDROPS # of sets administered _____  DEBRIEFING – Before patient leaves OR  Beta blockers?  PreOp Anticoagulant therapy (e.g., Warfarin)? Nurse reviews with entire team Important intra-operative events  Difficult Airway / Aspiration Risk  Specimen labeling and management (if required) Confirm equipment and assistance available  Ophthalmologist review:  Equipment Malfunction? Action taken? Specific patient concerns, critical steps, and special instruments or implants  _______________________________ Final optimal positioning of patient  _______________________________  Anesthesiologist(s) review(s)  _______________________________ Specific patient concerns, critical resuscitation plans, and warming devices required Changes to post-operative destination? ASA Class What are the KEY concerns for this patient’s  Nurses(s) review(s) recovery and management? Could anything have been done to make this Specific patient concerns? case safer or more efficient? Sterility indicator passed? Hand-off to RR Equipment issues? Correct implant (and back up) available?  Monitoring Pulse oximetry, ECG, BP